I am a plastic surgeon in Little Rock, AR. I used to "suture for a living", I continue "to live to sew". These days most of my sewing is piecing quilts. I love the patterns and interplay of the fabric color. I would like to explore writing about medical/surgical topics as well as sewing/quilting topics. I will do my best to make sure both are represented accurately as I share with both colleagues and the general public.

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Thursday, May 15, 2008

Updated 3/2017-- photos and all links removed as many are no longer active and it's easier than checking each one.

The Dermatology Journal Club (Elsevier) published a CME-related activity on "Achieving Optimal Outcomes with Dermal Fillers". It is reviewed two articles. The CME exam is available here, but I can't find the on-line publication of the journal. You will need to register to use the site, but it is free. The two articles are listed below under references. If you use dermal fillers, these articles are well worth reading. I reviewed several of the different fillers here. The results can be great as in the photo to the right (credit) when used properly.

Temporary side effects associated with all fillers include swelling, redness, itching, bruising, and mild pain.

Patients should limit their expressions and normal facial movements for 3 days after injection.

The face should also be protected from extreme cold postinjection (ie snowmobiling without facial protection).

By 3 months, permanent implants will have assumed their final shape. Touch-ups can provide additional symmetry and correction at this point.

Early complications include

Persistent erythema (long-lasting redness) is the most frequent early complaint. It is usually due to unintended intradermal injection. If the erythematous area is flat, then intense pulsed light (IPL) can be used to effectively reduce the lesion.

Ridges along the injection site and superficial beading are due to superficial intradermal injection and generally appear within 2 weeks. Injected strands (in particular those in the nasolabial folds) can separate unless an attempt is made to minimize motion at the injection site for 3 days. Limiting motion will allow the implanted material to become encapsulated and prevent it from dislocating.

Blanching after a particulate injectable indicates that a ridge may form later unless pressure is applied to the area to distribute the implant evenly.

Nodules will often appear within the first 4 weeks. They are often due to superficial or improper technique or inappropriate injection location. They tend to be small, isolated, well encapsulated, and respond poorly to intralesional steroids. They may require excision.

Late complications include

Hypertrophic scarring may occur in patients who are prone, but only if the substance is injected too superficially (intradermally).

Late inflammatory reactions include localized redness, swelling, and paresthesias. These can occur years after injection in all but the temporary fillers. Treatment with IPL or intralesional steriods is frequently effective.

Granulomas tend to appear 6-24 months after injection. They are true foreign-body reactions. They can occur despite proper injection technique. They are characterized by their late-onset rapid growth, inflammatory appearance, relatively large size, discoloration, and projections into surrounding tissues. They seem to appear simultaneously at all injection sites. They usually respond well to intralesional steroids.

Steroid atrophy, depending on the dose, may occur in 5-30% of patients treated for chronic redness, nodules, or granulomas.

Some physicians also use Sculptra for lateral eyebrows and dorsal hand areas.

Large areas, such as cheek hollows benefit from serial injections of very small volumes (0.1-0.2 mL or less) applied in a cross-hatched pattern. Advanced needle techniques such as fanning and retrograde tunneling using very small volumes work well in these areas. Specialized training and experience are necessary to utilize these techniques.

Sculptra should not be used in the body of the lip. This site offers a high probability of having nodules or papules form. Injections into the glabella and forehead are not recommended because of the risk of necrosis with any particulate product in these areas.

Nodule or papule development can be prevented by proper injection technique and appropriate identification of areas to be injected. Ice application postinjection may minimize bruising. A massage several times a day postinjection to the area can minimize papule formation.

great artichle and I have a question.... I think have a foreign body reaction to Aquamid. It came after 5 years at every injectionsite. You mentionsSteroid injections... what about steroid-pills instead, do they work?Sorry for any wrong spelled words, Im from overseas.

I think if you have a lump that is 1 cm, then it is a nodule and not too much filler (or really poorly placed filler). You should see a physician. It's difficult to tell anyone how many injections will be needed. Expect 3-5 to be needed and hope for 1-2.

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